Noninvasive diagnosis of Ascaris lumbricoides in the common bile duct: A pediatric case report of acute pancreatitis

Key Clinical Message This case report highlights the importance of considering parasitic infections, particularly Ascaris lumbricoides, as a possible cause of acute pancreatitis in children, especially in endemic regions. Noninvasive imaging techniques, such as ultrasonography, can play a crucial role in the early detection and diagnosis of this unusual presentation. Timely administration of anthelmintic therapy led to the resolution of symptoms and prevented the need for invasive procedures. Healthcare providers should be vigilant about the diverse clinical manifestations of ascariasis, and regular deworming programs and health education are essential in minimizing the burden of this neglected tropical disease among children. Abstract Ascariasis is a common public health problem globally but it is more prevalent in school‐age children and it often goes undiagnosed, leading to severe complications. The purpose of this report is to spread awareness of its unusual presentation and how to judiciously use noninvasive approaches for its diagnosis. We present a case of a 10‐year‐old girl that was presented in pediatric emergency with gradually worsening epigastric pain. Initial lab work‐up showed elevated pancreatic enzymes which lead to the diagnosis of acute pancreatitis. The patient was managed in the line of acute pancreatitis and with further evaluation by imaging techniques such as ultrasound and CT‐scan abdomen, Ascaris lumbricoides (A. lumbricoides) was visualized. She was then treated with prophylactic antibiotics and antiparasitic medications, which resolved her symptoms and the child responded to the treatment. In children, parasites should be considered as a cause of acute pancreatitis by clinicians, especially in low‐income countries, and before performing invasive procedures, noninvasive approaches should be considered as an initial option. This can save the patient from multiple invasive procedure and its severe complications.

present a case of a 10-year-old girl that was presented in pediatric emergency with gradually worsening epigastric pain.Initial lab work-up showed elevated pancreatic enzymes which lead to the diagnosis of acute pancreatitis.The patient was managed in the line of acute pancreatitis and with further evaluation by imaging techniques such as ultrasound and CT-scan abdomen, Ascaris lumbricoides (A.lumbricoides) was visualized.She was then treated with prophylactic antibiotics and antiparasitic medications, which resolved her symptoms and the child responded to the treatment.In children, parasites should be considered as a cause of acute pancreatitis by clinicians, especially in low-income countries, and before performing invasive procedures, noninvasive approaches should be considered as an initial option.This can save the patient from multiple invasive procedure and its severe complications.

| INTRODUCTION
Acute pancreatitis is a sudden and severe inflammation of the pancreas that presents with a state of severe abdominal pain and vomiting and may lead to a state of multiorgan dysfunction if not treated on time.Globally, an incidence of 3.6-13.2cases per 100,000 is reported every year with increased hospital admissions.Most commonly, the causes of acute pancreatitis include gallstones, alcohol intake, steroid use, trauma, autoimmune diseases, or infections in generals. 1scariasis lumbricoides is the largest helminth-round worm affecting humans and is one of the leading neglected parasites among children, especially the schoolgoing age group.It is endemic in developing countries due to poor sanitary conditions 2 and is common among tropical and subtropical countries.It has affected the population worldwide and in 2021, an estimate of more than 1.5 billion or 24% of the world's population was harbored with ascariasis cases. 3. lumbricoides leads to many acute or chronic manifestations and if left untreated it can be the cause of death among many.Most of the time, it remains asymptomatic and is diagnosed when a child is followed for malnutrition or poor weight gain that affects the child physically as well as academically. 4Typically, patients present with either diarrhea or altered bowel habits, worms in vomitus, or signs of intestinal obstruction 5 but very few extraintestinal presentations have been found.Here we describe a case of unusual presentation of A. lumbricoides being the cause of acute pancreatitis and its noninvasive diagnosis approach.

| CASE REPORT
A 10-year-old female child, resident of Landhi, Karachi, presented to the pediatric emergency department (ED) of The Indus Hospital, Karachi at night with a complain of upper abdominal pain for the last 4 days.She was a schoolgoing child in the 6th grade and used to play in the school playground or later in the evening with her friends daily.Her pain was initially mild to moderate in intensity, colicky in character and intermittent in nature and she had no prior known comorbid.The pain was localized to the epigastric region with no radiation.The patient was able to continue her daily routine but on the day before presenting to the ED, the intensity of pain increased several folds due to which she was unable to go to her school and was given painkillers at home, but her pain did not subside, after which the parents took the child to the Pediatric Emergency Department at The Indus Hospital, Karachi.The pain was not associated with fever, nausea, vomiting, diarrhea, altered bowel habits, or any other symptoms.
In the ED, the child was found to be in severe pain.On physical examination, she appeared pale and poorly nourished.She was vitally stable with a weight of 19 kg, blood pressure of 88/56 mmHg, temperature of 37.5°C, regular pulses with a rate of 98 beats per minute, and a respiratory rate of 26 breaths per minute.Systemic examinations performed included; respiratory examination which revealed equal air entry bilaterally with no added sounds, cardiac examination was unremarkable, there were normal S1 and S2 heart sounds with no other added sounds, murmur, or thrill, central nervous system examination revealed no abnormal neurological signs, and abdominal examination showed severe tenderness and rigidity in the epigastric and left hypogastric region, mild hepatomegaly with smooth borders but no splenomegaly, shifting dullness, or fluid thrill were not appreciable and gut sounds were audible and appeared normal.On admission, a baseline workup was sent, which is presented in Table 1.
The patient was shifted to the ward with the impression of acute pancreatitis due to a tender abdomen along with raised serum amylase and lipase levels.Her parents were further inquired about any recent trauma or procedure history, use of any medications, history of mumps, or any recent infection to rule out different causes of acute pancreatitis but nothing significant was report in the history.Following history, a hepatobiliary ultrasonography was performed to rule out any gall stone obstruction, perforation, or congenital pancreatic anomalies.The ultrasound showed hepatomegaly and mildly dilated common bile duct (CBD) with a diameter of 0.8 cm, while the gall bladder, pancreas, kidney, and spleen appeared normal in size and shape.Initially, the child was managed on the line of acute pancreatitis, by keeping the child nil per oral and on 100% maintenance fluid.Pain killers were given to relieve the pain, and prophylactic antibiotic injection, ceftriaxone, was started with a dose of 10 mg/kg to treat any possible infectious causes and before starting antibiotics, blood cultures were sent to rule out the causing pathogen.The child's condition did not appear to improve, and her fever started to progressively get more and more severe, while complains of epigastric pain and vomiting continued despite appropriate painkillers and antiemetics.To confirm the cause of the dilated CBD and acute pancreatitis, a Contrast Enhanced Computed Tomography scan (CECT-scan) of the abdomen was performed the next morning to get a cross-sectional imaging of the pancreas that is, its anatomical structures and any visible inflammation.CT abdomen with contrast was done under sedation which showed a bulky appearing pancreas with surrounding fat strandings and loss of normal feathery appearance.No evidence of peripancreatic fluid collection or parenchymal necrosis was seen.These findings correlated with mild acute pancreatitis.The CT abdomen also showed the liver to be enlarged with a mildly dilated CBD but no evidence of any calculus within CBD or gall bladder.There were also linear hypodense areas seen in the left proximal jejunum, suggestive of ascariasis (Figures 1 and 2).
Upon the suspicion of ascariasis, the decision to deworm the patient was taken in the evening on the same day by using Mebendazole syrup 100 mg twice daily for 3 days, and a pediatric gastroenterologist was consulted for the requirement of any intervention.The gastroenterologist advised to repeat an ultrasound of the hepatobiliary system in the morning and to continue to deworm the patient.Repeat hepatobiliary ultrasound on the next day showed the gall bladder to be normally distended, along with dilated CBD with a diameter of 0.8 cm and evidence of linear tubular structure within CBD extending in the left intrahepatic ducts representing ascariasis (Figure 3).With the deworming continued, the patient's condition started improving and on the third day of admission, the child passed two worms, milky white in color, cylindrical shaped, around 10-12 cm in size, through vomiting, and her symptoms of colicky pain resolved completely afterward.Initially, she was started with clear fluids and later with a fat-free diet as her lipase and amylase levels were slightly higher than normal but were improved as compared to the initial lab results.She was then sent home as she completed her 3 days dose of mebendazole, she remained symptom-free for 24 h and started tolerating oral diet.She was given antibiotics as prophylaxis for 5 days during her stay at hospital, until blood cultures reported F I G U R E 1 CT abdomen of the patient (axial view).

F I G U R E 2 CT abdomen of the patient (coronal view).
F I G U R E 3 Hepatobiliary ultrasound of the patient.
negative and was called for follow-up after 10 days in the outpatient pediatrics department with a fresh serum amylase and lipase sample and was advised to take fat-free diets till her labs get settled.

| DISCUSSION
Ascariasis is the most common helminth parasite around the globe, commonly found in the underdeveloped countries where sanitary conditions and hygiene are least focused on. 2 The 2016 Global Burden Data reported ascariasis to be the most common soil-transmitted helminth infection in Pakistan, with a prevalence of 13.1%. 6The cases are higher among school-going children, as they play with soil and in poor hygienic conditions, and not timely deworming of the children, or undertreatment can increase the susceptibility of these cases. 7Its mode of transmission is by fecal-oral route or skin penetration.The fertilized eggs of the species that grow in the intestine invade the mucosal layer and enter systemic circulation. 8scariasis, a soil-transmitted helminth infection can present in different ways, depending upon the worm's load.Most of the time, patients remain asymptomatic while sometimes they may present with either acute symptoms of abdominal discomfort or altered bowel habits, or present as a chronic case with symptoms such as cough and dyspnea when the organism involves the pulmonary system, or with malnutrition, 9 that is, not gaining adequate weight, micronutrient deficiency, and anemia.With increased worm load or chronic cases when worms grow up to adult size, the motile organism can cause multiple complications such as intestinal obstruction 10 or follow an unusual path and present as acute pancreatitis.It does so by the worm's migration via the ampullary orifice first blocking the pancreatic duct and causing symptoms of pancreatitis and then entering the CBD, where it causes a dilated CBD, as was reported in our patient. 11n patients with acute pancreatitis, gallstones, history of trauma, drug use, hypercholesterolemia, and autoimmune diseases are considered some of the common causes among children.When all the above causes rule out, one should think of parasites.Hussain et al. case report demonstrates the worms being the cause of acute pancreatitis in a 25-year-old man. 12A similar case series has been published in the International Journal of Medical Research & Health Sciences which showed that in cases of acute pancreatitis where other causes are ruled out, endoscopic retrograde cholangiopancreatography (ERCP), an invasive procedure, should be performed, as the investigation to look for ascariasis-induced acute pancreatitis, but no case has been reported in which ultrasonography, a noninvasive procedure was able to detect the roundworms and was treated empirically. 13This should be considered as an initial diagnosis measure, and when suspicion is too high and initial scan is normal, repeat scans should be performed to diagnose and prevent complications of intestinal obstruction to save the patient from invasive procedures and its side effects.

| CONCLUSION
This rare case of Ascaris lumbricoides-induced acute pancreatitis highlights the importance of considering parasitic infections in the differential diagnosis, especially in endemic regions.Ultrasonography proves to be a valuable noninvasive tool for early detection and guiding empirical treatment, particularly in resource-constrained settings.Timely administration of anthelmintic therapy resolved symptoms, avoiding unnecessary invasive procedures.Increased awareness among healthcare providers about diverse clinical presentations and the importance of deworming programs can help minimize the burden of helminthic infections.Further studies are needed to explore extraintestinal manifestations and validate ultrasonography as a diagnostic tool.Early detection and appropriate management can significantly improve outcomes for patients with ascariasis-induced complications.

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E Y W O R D S acute pancreatitis, Ascaris lumbricoides, case report, noninvasive approach T A B L E 1 Baseline work-up.